835 HIPAA Transaction Companion Guide HIPAA/005010X221A1 VERSION: 1.0 DATE: 12/31/2013

Transcription

1 835 HIPAA Transaction Companion Guide HIPAA/005010X221A1 VERSION: 1.0 DATE: 12/31/

2 Disclosure Statement This material contains confidential, proprietary information. Unauthorized use or disclosure of the information is strictly prohibited. The information in this document is furnished for Aetna Senior Supplemental Insurance (Aetna SSI) and Trading Partner use only. Changes are periodically made to the information in this document; these changes will be incorporated in new editions of this publication. Aetna Senior Supplemental Insurance may make improvements and/or changes in the product and/or program described in this publication at any time. Below are the Medicare Supplement companies that are either owned or administered by Aetna Senior Supplemental Insurance. Payer ID for all the companies for Electronic Remittance Advice transactions, EDI 835 is These companies will be referred as Aetna SSI in the document hereinafter. Aetna Health and Life Insurance Company Aetna Life Insurance Company Allianz Life Insurance Company of New York American Continental Insurance Company American General Life Insurance Company Combined Insurance Company of America Continental Life Insurance Company of Brentwood, Tennessee Genworth Life and Annuity Insurance Company Genworth Life Insurance Company Union Fidelity Life Insurance Company Virginia Surety Company, Inc. Washington National Insurance Company 2

3 Preface This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Aetna SSI. Transmissions based on this Companion Guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. 3

4 EDITOR S NOTE: This page is blank because major sections of a book should begin on a right hand page. 4

5 Table of Contents 1. INTRODUCTION... 6 SCOPE... 6 OVERVIEW... 6 REFERENCES... 7 ADDITIONAL INFORMATION GETTING STARTED... 7 WORKING WITH AETNA SSI... 7 TRADING PARTNER REGISTRATION... 8 CERTIFICATION AND TESTING OVERVIEW TESTING WITH THE PAYER CONNECTIVITY WITH THE PAYER/COMMUNICATIONS... 8 PROCESS FLOW... 8 TRANSMISSION ADMINISTRATIVE PROCEDURES... 9 RE-TRANSMISSION PROCEDURE... 9 COMMUNICATION PROTOCOL SPECIFICATIONS... 9 PASSWORDS CONTACT INFORMATION EDI CUSTOMER SERVICE EDI TECHNICAL ASSISTANCE PROVIDER SERVICE NUMBER APPLICABLE WEBSITES/ CONTROL SEGMENTS/ENVELOPES ISA/IEA GS-GE ST-SE PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ACKNOWLEDGEMENTS AND/OR REPORTS REPORT INVENTORY... Error! Bookmark not defined. 9. TRADING PARTNER AGREEMENTS TRANSACTION SPECIFIC INFORMATION

6 1. INTRODUCTION This is the Companion Guide to the v5010 ASC X12N 835 Implementation Guides and associated errata adopted under HIPAA; clarifies and specifies the data content when exchanging eligibility data electronically with Aetna SSI. Transmissions based on this Companion Guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. SCOPE This Companion Guide is intended for Trading Partners trading ASC/X12N transactions with Aetna SSI. The purpose of the Communications/Connectivity Guide is to convey the information needed to commence and maintain communication exchange with Aetna SSI s clearing house Real-Time Exchange Services, for the purpose of conducting real-time X12N Eligibility/Benefit Inquiry and Response transactions. This guide is intended to supplement information from the ASC X12 Technical Reports Type 3 (TR3s). OVERVIEW This guide is composed of the following sections: Section 1 Introduction: scope, overview, and related references. Section 2 Getting Started: How to interact with Aetna SSI s clearing house implementation team, how to register as a trading partner and complete payer enrollment, and an overview of testing and certification. Section 3 Testing with Aetna SSI: Details about the testing and certifying process. Section 4 Connectivity with Aetna SSI Clearing House/Communications: process flows, transmission administrative procedures, communication protocols, security protocols, and passwords. Section 5 Contact Information: How to get help. Section 6 Control Segments/Envelopes: ISA/ISE, GS/GE, and ST/SE values specific to Aetna SSI s clearing house. Section 7 Payer Specific Business Rules and Limitations: Describes Aetna SSI s business rules. Section 8 Acknowledgements and Reports: Information about Aetna SSI s use of acknowledgements and reports. Section 9 Trading Partner Agreements: Instructions regarding agreements that must be made between trading partners. Section 10 Transaction Specific Information: general supplemental instructions for each of the HIPAA-adopted transaction types. 6

7 REFERENCES ASC X12 Technical Reports Type 3 (TR3s) ASC X12 publishes TR3 s, which define the data contents and compliance requirements for the Health care implementation of the ASC X12/005010X221A1 Health Care Claim Payment/Advice (835) transaction sets. The following TR3 is referenced in this guide: ASC X12N/005010X221A1 Health Care Claim Payment/Advice (835) You are expected to comply with the requirements set forth in the TR3s. You can purchase these guides from the ASC X12 store at or from Washington Publishing Company ( The TR3s are copyrighted. ADDITIONAL INFORMATION For getting Information of Patient Eligibility for Aetna SSI companies, trading partners have to develop a connection between your interface and Emdeon. For more detailed information refer to Emdeon Companion guide at This Companion Guide assumes that you, the reader, are a representative of the Trading Partner, and that as such, you understand basic X12 structure, looping, and standard data requirements as set forth in the TR3 for each transaction set you wish to exchange. This Companion Guide also assumes that: You have a real-time EDI interface that supports the transaction sets the Trading Partner wishes to exchange. You have resources to develop a connection between your interface and Emdeon. 2. GETTING STARTED WORKING WITH AETNA SSI AETNA SSI currently uses Emdeon as their exclusive clearinghouse for managing EDI 835 connections. This guide includes the instructions you will need to get connected and start receiving standard 835 transactions with Emdeon. Make sure you read the entire guide in order to take advantage of the full functionality of the system. 7

8 TRADING PARTNER REGISTRATION Before submitting or receiving an 835 transaction, you must register as a Trading Partner with Emdeon to ensure you are established and recognized in the system. Use the ERA Provider Setup Form to initiate your Emdeon Setup. This form can be located at Complete the Provider Setup Form and submit to: batchenrollment@emdeon.com Fax: CERTIFICATION AND TESTING OVERVIEW The interface with Emdeon will involve utilization of Emdeon s proprietary software suite. Trading Partners who have not used it before may need to go through a testing phase with Emdeon. 3. TESTING WITH THE PAYER Aetna SSI does not support testing for ERA transactions. Once you enroll with Emdeon under Payer ID you will automatically start receiving EDI 835 s from Emdeon if any issues in connection please contact CONNECTIVITY WITH THE PAYER/COMMUNICATIONS PROCESS FLOW The process flow for the 835 transaction exchange will involve three separate entities: Aetna SSI, the provider or clearinghouse, and Emdeon. Emdeon will serve as an intermediary between the source and Aetna SSI, exchanging the electronic remittance advices and electronic payments through their secure connections with both entities. 8

9 TRANSMISSION ADMINISTRATIVE PROCEDURES Aetna SSI and its clearing house Emdeon will disburse the claim amount via EFT or Cheque and ERA or EOP on an average within 3 to 6 business days after receiving the claim from CMS. Remember we are Medigap Company and adjudicate only the claims which are primarily adjudicated by CMS. To expedite the process of payment please submit a COB claim to CMS, CMS will send Aetna SSI the secondary claim. RE-TRANSMISSION PROCEDURE Aetna SSI s and its clearing house Emdeon do not perform re-transmissions. COMMUNICATION PROTOCOL SPECIFICATIONS As you have to set up connection with Emdeon for receiving EDI 835 please refer to Emdeon Please refer to Emdeon Internet transactions services guide at PASSWORDS The use of passwords will be described in the ITS CORE users guide (the link above). 9

10 5. CONTACT INFORMATION EDI CUSTOMER SERVICE For customer service type inquiries in relation to the 835 setup and its efficiency, please contact Emdeon EDI EDI TECHNICAL ASSISTANCE For EDI technical assistance, please contact Emdeon EDI PROVIDER SERVICE NUMBER For provider services, please contact Aetna , option 2. APPLICABLE WEBSITES/ For more about Aetna SSI, visit our website at or us at aetssiinformation@aetna.com. 6. CONTROL SEGMENTS/ENVELOPES ISA/IEA The following is what Aetna SSI s clearing house Emden would be sending in 835 s as far the interchange control segments. It includes a description of expected sender and receiver codes, authorization information, and delimiters, for both the Interchange Control Header (ISA) and the Interchange Control Trailer (IEA). ISA RECORD LAYOUT Reference Designator Usage Description Possible Values (preferred in bold) ISA01 R Authorization Information Qualifier ISA02 R Authorization Information blank ISA03 R Security Information Qualifier ISA04 R Security Information TPG Serial Number ISA05 R Interchange ID Qualifier ZZ 2 2 ISA06 R Interchange Sender ID TPG Terminal Number ISA07 R Interchange ID Qualifier ZZ 2 2 ISA08 R Interchange Receiver ID EMDEON ISA09 R Interchange Date YYMMDD format 6 6 ISA10 R Interchange Time HHMM format 4 4 ISA11 R Repetition Separator >, :, 1 1 ISA12 R Interchange Control Version No ISA13 R Interchange Control Number See TR3 9 9 ISA14 R Acknowledgement Requested ISA15 R Usage Indicator P 1 1 Min Max 10

11 ISA16 R Component Element Separator : 1 1 Segment Terminator ~ 1 1 IEA RECORD LAYOUT Reference Designator Usage Description Possible Values Min Max IEA01 R Number of Included Functional Groups IEA02 R Group Control Number (must match ISA13) 9 9 GS-GE The following is what Aetna SSI s clearing house Emden would be sending in 835 s as far as the functional group control segments. It includes a description of expected application sender and receiver codes, for both the Group Control Header (GS) and the Group Control Trailer (GE). On inbound transmissions, we expect the trading partner to define the group control number to be sent. On outbound transmissions Aetna SSI will generate a unique sequenced control number. Aetna SSI s Real-Time Exchange Services support only one functional group per request and response. GS RECORD LAYOUT Reference Designator Usage Description Possible Values Min Max GS01 R Functional Identifier Code HS (inbound) 2 2 GS02 R Application Sender s Code (defined by sender) 2 15 GS03 R Application Receiver s Code MTEXE 2 15 GS04 R Date CCYYMMDD fmt 8 8 GS05 R Time HHMM format 4 8 GS06 R Group Control Number (defined by sender) 1 9 GS07 R Responsible Agency Code X 1 2 GS08 R Version/Release/Industry Identifier X221A GE RECORD LAYOUT Reference Designator Usage Description Possible Values Min Max GE01 R Number of Transaction Sets Included 1 6 GE02 R Group Control Number (must match GS06) 1 9 ST-SE The following is what Aetna SSI s clearing house Emden would be sending in 835 s as far as the transaction set segments. It includes a description of expected transaction codes, for both the Transaction Set Header (ST) and the Transaction Set Trailer (SE). ST RECORD LAYOUT 11

12 Reference Designator Usage Description Possible Values Min Max ST01 R Transaction Set Identifier Code ST02 R Transaction Set Control Number (incrementing no.) 4 9 ST03 R Implementation Convention Ref X221A SE RECORD LAYOUT Reference Designator Usage Description Possible Values Min Max SE01 R Number of Included Segments 1 10 SE02 R Transaction Set Control Number (must match ST02) PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS Providers will receive one consolidated payment and ERA for all the patients per entity group described on page 2 for all the claims processed every week. Emdeon s Rule ERA processing occurs hourly each day of the week. Each evening the system will distribute any ERA files that were received within the previous 24 hour period. Once processing is completed, ERA files are available for pick up by the client. 8. ACKNOWLEDGEMENTS AND/OR REPORTS It is the CORE certified submitters responsibility to produce a 999 within 2 hours receipt of the batch transaction. If the submitter is not CORE certified then a 999 is not required. 9. TRADING PARTNER AGREEMENTS This section contains general information concerning Trading Partner Agreements (TPA). TRADING PARTNERS An EDI Trading Partner is defined as any Aetna SSI s customer (provider, billing service, software vendor, employer group, financial institution, etc.) that transmits to, or receives electronic data from Aetna SSI. 12

13 Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. For example, a Trading Partner Agreement may specify among other things, the roles and responsibilities of each party to the agreement in conducting standard transactions. As Aetna SSI only will be directly exchanging data with Emdeon, the existing Trading Partner Agreement between Aetna SSI and Emdeon will cover these transmissions. It may be necessary for those originating these transactions to complete similar documents with Emdeon. 10. TRANSACTION SPECIFIC INFORMATION The tables contain a row for each segment that Aetna SSI has something additional, over and above, the information in the IGs. Loop ID 1000A Segment/ Element ID NM1 01 Data Element Name Information Source Name Entity Identifier Code 03 Payer Name Aetna SSI Business Rule PR Aetna Health and Life Insurance Company Aetna Life Insurance Company American Continental Insurance Company American General Life Insurance Company Allianz Life Insurance Company of New York Combined Insurance Company of America Continental Life Insurance Company of Brentwood, Tennessee Genworth Life and Annuity Insurance Company Genworth Life Insurance Company Union Fidelity Life Insurance Company Virginia Surety Company, Inc. Washington National Insurance Company Notes/Comments The ERA will have either of these payer names depending upon which company the claim is submitted under. 13